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�- � � . ^ � �� ����T(� <br /> ��� <br /> sr�tg. Post Office Box 66•Crystal Bay,Minnesota 50323•Municipal Of6ces <br /> � a; <br /> .�,� _��, � � On the North Shore of Lake Minnetonka <br /> DATA__PR_IVACY ADVISORY <br /> In accordance with M.S. 15.165, "Rights of subjects of data", we <br /> would Iike to inform you that your request for a permit or Iicense <br /> from the City of Orono or any of its departments may reguire you to <br /> furnish certain private or confidential. information. <br /> You are notified that: <br /> 1. The information you furnish will be used to determine your <br /> quaZification for the permit or license recruested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or Iicense. <br /> 3. The information may be shared with other local , state or <br /> federal agencies to the extent necessary to process the pernit or <br /> �icense. <br /> 4. If your requested permit or Iicense rec�uires Counci� action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 15.165 to review private <br /> data on yourself. <br /> 6. Your full name, and date of birth are required to process <br /> this,-application or permit. <br /> � , ,�, . <br /> � , �_ <br /> � � <br /> '�� .� - --- - -`Z'� <br /> � Middle Last <br /> First <br /> -� � � � �� <br /> ��% �x. � 7 ��^�.��� C �2 �- - �-----. _ . _ �- <br /> Address . _ <br /> / . ? `� <br /> � �f,j'� L7 � � <br /> � �G�� _ ��-� � �� - - -- --- - - - --- - <br /> � i /��/ � :_) . <br /> /� L . l J! _'.""".....__."___ '"_" " . .. . . <br /> (.��.�. ._ �......__"_. .._. .. . _ ..1�..�......__..._. . _ _ <br /> City ✓ State Zip <br /> l� -1 � `� f 1 �� -- -- --- - <br /> Phone <br /> I understand my rights as stated above. <br /> ;� i � <br /> , �-- <br /> . <br /> � r----� <br /> � � ��� <br /> ; . <br /> � - --- -- ------ <br /> � - - ------ ..-------- <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br /> 5 <br />